Outcome of surgical treatment of

peri-implantitis: results from a 2-year

prospective clinical study in humans
Giovanni Serino
Alberto Turri
Authors afliations:
Giovanni Serino, Alberto Turri, Specialistic Clinic in
Periodontics, So dra A

lvsborgs Hospital, Boras 50182,

Sweden
Alberto Turri, Specialistic Clinic in Periodontics,
Odontologen, Go teborg, Sweden
Giovanni Serino, Research and Developments Unit,
Boras, Sweden.
Corresponding author:
Giovanni Serino
Specialistic Clinic in Periodontics
So dra A

lvsborgs Hospital
Boras 50182
Sweden
Tel.: 46 033 616 2802
Fax: 46 033 616 1235
e-mail: giovanni.serino@vgregion.se
Key words: peri-implantitis, peri-implant bone loss, peri-implant surgery, surgery outcome
Abstract
Aim: The aim of the present study was to evaluate the outcome of a surgical procedure based on
pocket elimination and bone re-contouring for the treatment of peri-implantitis.
Material and methods: The 31 subjects involved in this study presented clinical signs of peri-
implantitis at one or more dental implants (i.e. 6 mm pockets, bleeding on probing and/or
suppuration and radiographic evidence of 2 mm bone loss). The patients were treated with a
surgical procedure based on pocket elimination and bone re-contouring and plaque control before
and following the surgery. At the time of surgery, the amount of bone loss at implants was recorded.
Results: Two years following treatment, 15 (48%) subjects had no signs of peri-implant disease; 24
patients (77%) had no implants with a probing pocket depth of 6 mm associated with bleeding
and/or suppuration following probing. A total of 36 implants (42%) out of the 86 with initial diagnosis
of peri-implantitis presented peri-implant disease despite treatment. The proportion of implants that
became healthy following treatment was higher for those with minor initial bone loss (24mm bone
loss as assessed during surgery) compared with the implants with a bone loss of 5 mm (74% vs.
40%). Among the 18 implants with bone loss of 7 mm, seven were extracted. Between the 6-month
and the 2-year examination, healthy implants following treatment tended to remain stable, while
deepening of pockets was observed for those implants with residual pockets.
Conclusion: The results of this study indicated that a surgical procedure based on pocket elimination
and bone re-contouring and plaque control before and following surgery was an effective therapy for
treatment of peri-implantitis for the majority of subjects and implants. However, complete disease
resolution at the site level seems to depend on the initial bone loss at implants. Implants with no signs
of peri-implantitis following treatment tended to remain healthy during the 2-year period, while a
tendency for disease progression was observed for the implants that still showed signs of peri-implant
disease following treatment.
Bleeding and/or suppuration following probing
has been proposed as a valuable clinical sign for
the diagnosis of both peri-implant mucositis and
peri-implantitis while the concomitant detection
of marginal peri-implant bone loss in radiographs
will distinguish a peri-implantitis from a muco-
sitis (Zitzmann & Berglundh 2008).
Bacteria play a major role in the aetiology of
peri-implant mucositis and peri-implantitis (Pon-
toriero et al. 1994; Augthun & Conrads 1997;
Mombelli & Lang 1998; Leonhardt et al. 1999;
Quirynen et al. 2002, 2006). Animal experi-
ments have shown that plaque accumulation on
the implant surfaces seems to be critical to the
development of peri-implant diseases (Berglundh
et al. 1992; Ericsson et al. 1992; Lang et al. 1994)
and may be responsible for altering the biocom-
patibility of the implant surfaces. Thus, the
treatment of both mucositis and peri-implantitis
in human is based on plaque removal from the
implant surfaces. With this type of treatment two
questions arise:
(1) Is it possible to re-establish healthy condition
for the tissues of an implant affected by peri-
implant disease? Regarding this question,
plaque removal using a non-surgical debride-
ment/decontamination of the implant sur-
faces seems to be effective in the treatment
of peri-implant mucositis, while limited effect
of this procedure has been reported for the
treatment of peri-implantitis (for review see
Renvert et al. 2008a, 2008b); experimental
studies have shown resolution of peri-implan-
titis following the surgical exposure of the
implants and the mechanical debridement/
decontamination of the implant surfaces (for
review see Claffey et al. 2008).
Date:
Accepted 5 October 2010
To cite this article:
Serino G, Turri A. Outcome of surgical treatment of peri-
implantitis: results from a 2-year prospective clinical study
in humans.
Clin. Oral Impl. Res. 22, 2011; 12141220.
doi: 10.1111/j.1600-0501.2010.02098.x
1214 c 2011 John Wiley & Sons A/S
(2) Might osseointegration eventually occur on
previously contaminated implant surfaces?
Recent experimental animal studies have
shown that it is possible to obtain re-osseoin-
tegration on a decontaminated implant sur-
face, if the implants are placed in freshly
prepared alveola bone (Kolonidis et al. 2003;
Alhag et al. 2008). However, non-predictable
re-osseointegration from the surrounding
bone on a decontaminated implant surface
has been observed if the implants are left in
their original position. Histological results
demonstrated a connective tissue capsule se-
parating the implant surface fromthe adjacent
bone in most cases, except at the most apical
extent of the defect (Grunder et al. 1993;
Ericsson et al. 1996; Persson et al. 1996,
1999, 2001, 2004; Schwartz et al. 2006a).
The effect of access surgery combined with
surface debridement/decontamination of the im-
plants affected by peri-implantitis in human has
been investigated in a few studies involving lim-
ited numbers of patients (for review see Claffey et
al. 2008; Esposito et al. 2008). In one study
involving nine patients witha total of 26 implants,
Leonhardt et al. (2003) tested a treatment based on
surgical debridement and the use of hydrogen
peroxide for the decontamination of the implant
surfaces under systemic antibiotic administration.
Based on radiographic evaluation, the authors
reported that 58% of the treated implants did
not show progression of bone loss at the 5-year
follow-up radiographic examination. Romeo et al.
(2005, 2007) tested on 19 patients the efcacy of
resective surgery based on removal of granulation
tissue around the affected implants, polishing of
the implant surfaces using local antibiotics and
correction of the anatomical architecture of the
bone. In addition, modication of the implant
surface topography (implantoplasty) was per-
formed in nine of those patients. A total of 35
implants with peri-implantitis were treated. The
results at the third year examination showed that
the treatment including the implantoplasty
seemed to inuence positively the survival of
implants affected by peri-implantitis and reduce
the peri-implant pockets depth, suppuration and
sulcus bleeding. The radiographic examination
showed lower marginal alveolar bone loss around
implants treated with implantoplasty compared
with the control implants. In a recent short-term
clinical study (Maximo et al. 2009), the authors
presented the clinical results of a treatment of peri-
implantitis based on only open ap mechanical
debridement of 20 implants (in a total of 13
patients). Three months following the treatment,
25% of the treated implants presented clinical
signs of peri-implantitis (i.e. PPD 5mmBoP
and/or suppuration at least at one site).
Although the mentioned clinical studies seem
to indicate healthier conditions of the peri-im-
plant mucosa following the treatment of peri-
implantitis, the clinical parameters used to eval-
uate the treatment outcomes vary between stu-
dies. Currently, there is no consensus on which
clinical parameters should distinguish a condi-
tion of health or disease following treatment of
peri-implantitis.
Aim
The aim of the present study was to evaluate the
outcome of the routine surgical procedure pro-
vided in our clinic for the treatment of peri-
implantitis. The surgical procedure was based
on pocket elimination and bone re-contouring.
Material and methods
Patient recruitment
The subjects involved in this study were selected
from consecutive patients referred to the depart-
ment of Periodontology, So dra A

lvsborgs Hospi-
tal, Boras, Sweden, for treatment of peri-
implantitis during 20052007. The 2-year fol-
low-up was the end point of the recruitment.
Inclusion criteria
To be included in this study, the patients had
clinical signs of peri-implantitis at one or more
dental implants (i.e. PPD 6 mm, bleeding on
probing and/or suppuration) and radiographic
evidence of bone loss ( 2 mm at mesial or distal
site of the implants). The implants should have
been in function for more than 1 year. Both
edentulous and partial edentulous patients were
included.
Exclusion criteria
Any medical condition, which contraindicated
dental surgery, precluded the enrolment to the
study. Two subjects were not included, one
because of chemotherapy and the other because
of bisphosphonates.
Patient sample
The inclusion criteria resulted in the selection of
31 subjects of which 19 were female and 12 male.
Eight were smokers who all smoked more than
10cigarettes/day.
Following the clinical and radiographic exam-
ination, all patients were informed about the
diagnosis and treatment plan. They were also
informed that their data would be used for statis-
tical analyses and gave their informed consent to
the treatment.
The study was performed in accordance with
the principle stated in the Declaration of Hel-
sinki.
Clinical examination
The following clinical variables were recorded:
Plaque Index (PI) as percentage of sites with
the presence of plaque as determined at four
surfaces (mesial, distal, buccal, lingual) per
tooth/implant after staining with disclosing solu-
tion.
Access/Ability for oral hygiene at implant site:
At the time of the clinical examination, an
assessment of the restoration was made to deter-
mine if access for OH had been provided (yes/no).
When there was access, the quality of the pa-
tients current home care was assessed by run-
ning the probe across the marginal surface of the
implant and recording either the absence or the
presence of plaque based on the modied PI
(Mombelli et al. 1987) in the following way: no
plaque score 0; plaque present score 1, 2, 3.
Positive or negative value (yes/no) was recorded
for each implant.
Modied Sulcus Bleeding Index (mBI): pre-
sence or absence of bleeding was recorded by
running the probe along the soft tissue margin
of the implants. Bleeding was recorded if any site
of the implants was positive to the test (score 1,
2, 3 Mombelli et al. 1987).
Bleeding/Suppuration on Probing (BoP/Sup)
presence or absence of bleeding/suppuration up
to 15 seconds after probing was assessed.
Probing Pocket Depth (PPD) was measured in
millimeters with a manual Hu-Friedy PCP15
periodontal probe (Hu-Friedy Inc., Leimen, Ger-
many) to the closest millimetre at the mesial,
buccal, distal and lingual surfaces of all implants.
Bone Loss at implants: during the surgery,
following the elevation of the aps and the
removal of the granulation tissue, the bone loss
was measured around each implant to the nearest
mm with the periodontal probe. Depending on
the implant system, the bone loss was measured
either from xtureabutment junction (Brane-
mark
s
[Nobel Biocare, Gothenburg, Sweden],
Astra Tech
s
[Mo lndal, Sweden]) or the shoulder
of the implants (ITI
s
[Straumann Institute AG,
Waldenburg, Switzerland]) to the level where the
bone was seen to be in intimate contact with the
implant. The highest value at any site around
each affected implant was recorded.
Radiographic examination
Radiographic bone loss was evaluated from peri-
apical radiographs and measured fromthe xture
abutment junction/shoulder of the implants,
respectively, to the bone level mesial and distal
to the implants. For the purpose of this study, the
Serino & Turri Outcome of surgical treatment of peri-implantitis
c 2011 John Wiley & Sons A/S 1215 | Clin. Oral Impl. Res. 22, 2011 / 12141220
radiographic threshold value to discriminate bone
loss at implants was 2mm.
Implant grouping
According to the clinical and radiographic data at
the baseline examination, the implants were
divided into one of the following groups:
Healthy PPDo4 mm without BoP and/or
Sup and no radiographic bone loss;
Mucositis PPD 4 mm at least at one site,
associated with Bop and/or Sup without radio-
graphic bone loss;
Peri-implantitis PPD 6 mm at least at
one site, associated with BoP and/or Sup and
concomitant radiographic images of bone loss
of 2 mm.
Treatment
Pre-surgical phase
Any prosthesis, which had been assessed as
having poor access for OH at baseline, was
removed and the form was corrected. This was
facilitated by themall being screw-retained. Each
patient was then given OH and supra/sub-gingi-
val scaling by dental hygienists to treat gingivitis
and mucositis. Any patients with remaining
natural dentition exhibiting periodontal disease
were given conventional periodontal treatment.
However, the severity of periodontitis in these
subjects was limited (for details see Serino &
Stro m 2009).
Once all these stages were completed (13
months according to individual patient needs)
and the standard of OH was considered appro-
priate (PlIo20% around natural dentition and
modied PI score of 0 around the implants), the
surgical treatment was planned.
Surgical phase
One day before the surgery, all patients received
systemic antibiotic prophylactic therapy (Dalacin
s
,
[Pzer Sollentuna, Sweden], tabl. 300mg 3/day
for 1 week). To facilitate good surgical access
around the implants, the prostheses were removed
(for all but two of the subjects). Only sites showing
peri-implantitis were surgically treated.
The incision was made using a BardParker
blade (No. 15) under local anaesthesia (2% xylo-
caine/adrenaline). The positions of the incisions
were dependent on the pocket depth as well as the
width and thickness of the peri-implant mucosa.
Flaps were designed to optimize the removal of the
pocket epithelium and the inammatory granulo-
matous capsule from the internal aspects of the
mucoperiosteal ap and from the peri-implant
defect. Vertical releasing incisions extending into
the alveolar mucosa were placed at the mesial and
distal boundaries of the horizontal incisions. Mu-
coperiosteal full-thickness aps were raised buc-
cally and palatally/lingually. The granulation
tissue was removed using hand curettes. Correc-
tion of the anatomical architecture of the bone,
aiming to eliminate angular bony defect, was
performed using a rotating round bur under saline
irrigation. The implant surfaces were scaled and
polished using an ultrasonic instrument (EMS
Piezon Master 400Perio Slim Tips, EMS
s
,
Nyon, Switzerland) and rotating rubber cup under
chlorhexidine irrigation. In our hands, these in-
struments gave the possibility to remove plaque
and calculus more efciently compared with ti-
tatnium or carbon-bre curettes. The aps were
trimmed and apically repositioned, and the pros-
theses were re-tted.
Following surgery, the patients rinsed twice a
day for 1 min with chlorhexidine 0.12% for a
period of 2 weeks. The sutures were removed 10
days after the surgery. One week following suture
removal, the patients received new oral hygiene
instructions appropriate to the newcontour of the
peri-implant mucosa. The patients were recalled
at 3, 6, 12, 18 and 24 month for re-evaluation and
maintenance care. At each recall, the prostheses
were removed in order to have proper access for
implant examination. The maintenance care was
based on motivation and oral hygiene instruction
according to the patients need, supragingival
plaque control and subgingival scaling at im-
plants presenting residual pockets. The subgingi-
val scaling was performed using an ultrasound
instrument (EMS Piezon Master 400Perio
Slim/Perio Implant Tips, EMS
s
, Nyon, Switzer-
land). At the 3-month recall, any implants show-
ing deep pockets, pus formation and causing
discomfort to the patient were extracted.
Drop Out
Two of the 31 patients could not be examined at
the 2-year control, (one moved, one ill). The 1-
year data of these two patients were included in
the analyses.
Data analyses
Mean values ( SD) for subjects were used for
descriptive statistic. The non-paired t-test was
applied for the difference between smoker and
non-smokers. Fishers exact probability test was
applied at the subject level to assess difference in
probability of healing related to the two catego-
rical variables (implants with bone loss 24 vs.
5mm). A P-value of o0.05 was considered to
be statistically signicant.
Results
At the baseline examination, 31 patients (19
female) having one or more implants with signs
of peri-implantitis were examined; ve (16%) of
those were edentulous and eight were smokers
(who all smoked 410cigarette/day) (Table 1).
There was no statistical difference between the
mean number of implants with peri-implantitis
between smokers and non-smokers (2.8 1.5SD
vs. 3.0 1.5SD, P0.7). The majority of the
subjects (22) had up to three implants affected by
peri-implantitis, while nine had four, ve or six
(Fig. 1). A total number of 168 implants were
examined, 54 (32%) had a diagnosis of mucositis
and 86 (52%) of per-implantitis; 73 (44%) im-
plants were in function for more than 10 years, 51
(30%) between 5 and 10 years, and 44 (26%) o5
years. The majority of the implants (87%) were
machined surfaced implants. Marginal bleeding
was present at 89 (53%) implants and 105 (62%)
were assessed as having no access/ability for oral
hygiene (Table 1). Figure 2 shows the location as
well as the number of implants with different
degrees of bone loss; 58 implants with diagnosis
of peri-implantitis were located in the maxilla and
28 in the mandible. The highest number of
implants with advanced bone loss ( 7mm)
was found in the incisor area of the maxilla. No
implants were present in the molar area of the
maxilla and only four implants were located in the
molar areas of the mandible. Six subjects had all
the implants with peri-implantitis presenting a
bone loss of 24mm, 11 subjects had all the
implants witha bone loss of 56mm, two subjects
with 7mm bone loss, while 12 subjects had
all their implants presenting the three different
degrees of bone loss.
At the follow-up examinations, the number of
implants presenting marginal bleeding and no-
Table1. Baseline data of the 31 patients and the
168 implants
Number of patients 31
Age (years, mean SD) 63.2 (8.7)
Female 19
Number (%) edentulous 5(17%)
Number (%) partially edentulous 26(83%)
Number (%) smokers 8 (26%)
Function time and number of implants
o 5 years 44 (26%)
510 years 51 (30%)
410 years 73 (44%)
Tot. 168
Type and number of implants
Bra nemark
s
122
ITI
s
40
Astra
s
6
Surfaces and number of implants
Machined surfaced implants 146
Plasma sprayed implants 22
Number (%) of implants with no access
To oral hygiene 105 (62%)
Number (%) of implants with 89 (53%)
Marginal bleeding (MBI)
Number (%) of healthy implants 28 (16%)
Number (%) of mucositis 54 (32%)
Number (%) of peri-implantitis 86 (52%)
Total 168
Serino & Turri Outcome of surgical treatment of peri-implantitis
1216 | Clin. Oral Impl. Res. 22, 2011 / 12141220 c 2011 John Wiley & Sons A/S
access/ability for oral hygiene decreased notably
as a consequence of the improved access and
patients ability to brush around the neck of the
implants (Fig. 3). Figure 1 shows that 2 years
following treatment, 15 (48%) subjects had no
signs of peri-implant disease, i.e. no implants
presenting pocket associated with bleeding/sup-
puration; 24 patients (77%) had no implants with
PPD 6 mmBop/SuP. Four patients had one
implant with PPD 6 mmBoP/Sup, eight
patients had one implant with peri-implant dis-
ease. Only one patient had three implants with
6 mm PPDBop/Sup and two patients had
six implants with PPD of 45 mm PPDBop/
Sup. No statistical difference was found in the
mean number of implants with peri-implantitis
at the 2-year examination between smokers and
non-smokers (1.9 1.8 SD vs. 1.5 0.8 SD,
P0.7). Figure 4 shows that the number of
healthy implants following treatment remained
stable up to 2 years while the number of implants
presenting a PPD 6 mm associated with
bleeding/suppuration increased between the 6-
month and 2-year examination.
Following the 3-month examination seven
implants were extracted because of persisting
deep pockets, pus formation and patients discom-
fort; all these implants had a bone loss of
47mm. At the 2-year review, 14 implants
presented PPD 6 mm associated with bleed-
ing/suppuration and 15 implants had PPD 4
5 mmBop/Sup. Including the seven implants
that were extracted, a total of 36 implants (42%)
out of the 86 with an initial diagnosis of peri-
implantitis exhibited peri-implant disease despite
treatment. Table 2 shows the outcome of treat-
ment related to the initial severity of bone loss as
measured following ap elevation during surgery;
at the sixth month examination, 34 out of the 46
implants (74%) with an initial bone loss of 2
4 mm were healthy, compared with 50% of the
implants with initial bone loss of 56 mm. The
healing following treatment was evaluated for
each subject separately for the implants with 2
4 mm bone loss and for those with 56mm bone
loss. The results revealed that 10 out of 14
subjects presenting implant with initial bone
loss of 24mm, had all their implant healthy
following treatment (71% predict positive value
for healing); eight out of 17 subjects presenting
implants with initial bone loss of 56mm, had all
those implants healthy following treatment (32%
predict positive value for healing). The difference
in probability was statistically signicant (Two-
tail Fisher Exact Probability Test, P0.02). Of
the 18 implants with bone loss of 7 mm,
seven were extracted. Between the 6-month and
the 2-year examinations, the number of implants
with PPD of 6mm associated with BoP/SuP
increased in all three bone loss groups while
the number of healthy implants remained stable.
Discussion
The results of the present study indicate that a
surgical approach based on pocket elimination
and bone re-contouring associated with a proper
standard of self-performed plaque control, was an
effective means to treat peri-implantitis for the
0
5
10
15
20
25
30
0 1 2 3 4 5 6 . 0 1 2 3 4 5 6
Peri-impl
6mm PPD
4- 5mm and/or 6mm PPD
Number of implants
Baseline
2 years
N
u
m
b
e
r

o
f

s
u
b
j
e
c
t
s

Fig. 1. Data showing the number of subjects with respect to the number of implants affected by peri-implantitis (Baseline) and
post-treatment peri-implantitis condition at the 2-year examination. At the 2-year examination, 24 subjects did not present
implants with 6 mm PPD associated with BoP/SuP and 15 subjects did not have implants affected by peri-implant
disease.
7 mm
5 - 6 mm
2 - 4 mm
Incisor Canine Premolar Molar
Maxilla
Mandible
0
10
20
10
30
N
u
m
b
e
r

o
f

i
m
p
l
a
n
t
s

Fig. 2. Baseline data: number and location of implants with different degrees of bone loss. The highest number of implants
with bone loss of 7 mm was found in the incisor area of the maxilla.
0
20
40
60
80
100
120
Baseline 3 months 6 months 2 years
No Oral Hygiene
MBI
N
u
m
b
e
r

o
f

I
m
p
l
a
n
t
s

Fig. 3. The number of implants with no accessibility/ability for oral hygiene and marginal bleeding (MBI) was reduced
following the baseline examination.
Serino & Turri Outcome of surgical treatment of peri-implantitis
c 2011 John Wiley & Sons A/S 1217 | Clin. Oral Impl. Res. 22, 2011 / 12141220
majority of subjects and implants. Resolution of
the disease was a frequent nding for those
implants with minor initial bone loss (24mm)
while persistence of peri-implant disease tended
to be more frequent for those implants with an
initial advanced bone loss ( 5 mm).
The overall improvements of the clinical para-
meters following the treatment of peri-implanti-
tis observed in the present investigation are in
agreement with the results of those studies based
on surgical treatment of peri-implantitis (Leon-
hardt et al. 2003; Romeo et al. 2005, 2007;
Maximo et al. 2009). However, the parameters
used to evaluate the treatment outcome vary
among these studies. Leonhardt et al. (2003)
and Romeo et al. (2007) used radiographic bone
level change at implants to assess stability or
progression of disease following treatment, while
changes in clinical parameters compared with the
baseline data have been used in the studies by
Romeo et al. 2005 and Maximo et al. 2009.
Although radiographic examination is a valid
method for the assessment of bone level change
over time (Albrektsson & Sennerby 1991), clin-
ical changes would require some years before
they could be detected on radiographs. Further-
more, the radiographic assessment of marginal
bone loss is limited to the mesial and distal aspect
of the implants. It should be kept in mind that
when using changes in certain clinical or micro-
biological parameters for the treatment evalua-
tion, an improvement in the parameters could be
anticipated following a peri-implant treatment
based on supra and sub-gingival debridement/
decontamination, although complete and suc-
cessful resolution of the peri-implant disease
may not have been obtained (Mombelli et al.
2001; Karring et al. 2005; Salvi et al. 2007;
Renvert et al. 2007, 2009). In the consensus
report of the sixth European workshop of perio-
dontology, Lindhe & Meyle (2008) concluded
that effectiveness rather than efcacy should
be reported in the evaluation of peri-implant
therapy. However, currently there is no con-
sensus on which clinical parameters should the
effectiveness of peri-implant treatment be based
(Esposito et al. 2008). In our study, we chose
elimination of clinical signs of peri-implantitis as
goal of therapy and as well as treatment evalua-
tion. Consequently, we considered healthy fol-
lowing treatment for those implants without
pockets and no BoP/Sup (Fig. 5a), while persis-
tence of peri-implant disease was considered for
those implants exhibiting residual PPD of 4
5 mm (Fig. 5b) and 6 mm (Fig. 5c) associated
with BoP/sup. The rationale is that following
treatment, a healthy implant should be without
the clinical signs associated with the initial
diagnosis of peri-implantitis and the presence of
pocket depth with bleeding/suppuration is re-
garded as peri-implantitis (Zitzmann & Ber-
glundh 2008). The differentiation between
healthy, mucositis and peri-implantitis based on
bone loss/no bone loss around implants (Zitz-
mann & Berglundh 2008), it may not be applic-
able following the treatment of peri-implantitis,
because both the healthy and disease conditions
are now associated with bone loss around im-
plants.
Following surgery, although a residual pocket
of 45mm might be regarded as shallow, it must
be kept in mind that the peri-implant tissues
have been apically repositioned and may lie at or
below the head of the implant, on a rough and
threaded surface, as opposed to at the abutment
level in the pre-treatment situation. In our study,
during the 2-year follow-up, some of the im-
plants with PPD 45mm showed deepening of
the pockets despite maintenance consisting of
both supra and sub-mucosal mechanical debride-
ment. Salvi et al. (2007) and Renvert et al.
(2008a, 2008b) showed an improved and sus-
tained (1-year follow-up) clinical condition in
the treatment of incipient peri-implantitis
using local antibiotics in adjunct to the mechan-
ical debridement. Whether this treatment mod-
ality can be applied in a post-surgical residual
pocket needs further investigation.
In the present study, if the goal of therapy was
the elimination of the pockets 6 mm asso-
ciated with bleeding/suppuration around im-
plants, 77% of the subjects and 75% of the
implants were successfully treated. If the thresh-
old had been lowered to no pockets 4 mm,
the treatment would be only effective in 48% of
the subjects and 58% of the implants. Table 2
shows that the success rate (healthy implants)
was much higher if the implants had an initial
minor bone loss. Maximo et al. (2009) reported
resolution of disease in 75% of the implants with
peri-implantitis using no PPD 5 mm with
bleeding and/or suppuration as threshold value.
However, this result was obtained at the 3-
month evaluation following treatment of 13
patients and the severity of initial bone loss
around the implants was not reported. In our
study, efforts were carried out to ensure the
establishment of adequate plaque control before
and after the surgical procedure. The periodontal
treatment in the partially edentulous subjects, if
necessary, was also completed before the peri-
implant surgery. Furthermore, the prostheses on
the implants were modied to allow access for
proper oral hygiene, if needed. The improved
plaque control around the implants is reected
by the reduced number of implants showing
marginal bleeding (from n89 to 14). These
results were obtained following treatment and
were maintained over the 2-year follow-up. The
importance of plaque control on the onset of
mucositis has been shown in a clinical experi-
0
20
40
60
80
100
120
2 years
N
u
m
b
e
r

o
f

I
m
p
l
a
n
t
s

Baseline 3 months 6 months
Fig. 4. Number of implants with peri-implantitis at baseline and number of implants with or without probing pocket depth
and BoP/Sup following treatment is noticeable. An increased number of healthy implants at 6-month following treatment is
evident and this number remained stable up to the 2-year examination. The number of implants with 6 mm PPD was
higher at 2-year compared with the 6-month examination. Seven implants were extracted (Extr.) following the third-month
examination.
Table 2. The outcome of treatment related to the
bone loss at implant affected by peri-implantitis
Bone loss
24 mm 56 mm 7 mm
Treatment outcome
3 months
Healthy 38 17 6
45 mm (Bop/Sup) 8 3 4
6 mm (Bop/Sup) 0 2 1
Extraction 7
6 months
Healthy 34 11 4
45 mm (Bop/Sup) 12 8 4
6 mm (Bop/Sup) 0 3 3
Extraction
2 years
Healthy 34 12 4
45 mm (Bop/Sup) 7 4 4
6 mm (Bop/Sup) 5 6 3
Extraction
At the 6 month examination, 34 out of 46 (76%) im-
plants with initial bone loss of 24mm were healthy
compared with 11 out of 22 (50%) with initial bone
loss of 56mm. Among the 18 implants with bone loss
of 7 mm, 7 (39%) were extracted at the 3 months
examination.
Serino & Turri Outcome of surgical treatment of peri-implantitis
1218 | Clin. Oral Impl. Res. 22, 2011 / 12141220 c 2011 John Wiley & Sons A/S
mental study by Pontoriero et al. 1994. Peri-
implantitis and peri-implant radiographic bone
loss have been associated with inadequate plaque
control around implants (Lindquist et al. 1997;
Serino & Stro m 2009). It is interesting to note
that 74% of the patients with peri-implantitis
were non-smokers and no difference was noted in
the number of healthy implants following treat-
ment between smokers and non-smokers. Persis-
tence of disease was a frequent nding for those
implants with an initial advanced bone loss (bone
loss 7mm). In most of these cases, the ad-
vanced bone loss was associated with the pre-
sence of deep angular bony defect and the
presence of bony dehiscence at the buccal aspect
similar to the Class Id defects described by
Schwartz et al 2007. The presence of buccal bone
dehiscence associated with ligature-induced peri-
implantitis has been reported for those implants
placed close to the buccal bone (Parlar et al.
2009). Furthermore, in a retrospective study,
Alsaadi et al. (2008) analysed 1514 implants in
412 patients to evaluate the impact of local and
systemic factors on the incidence of late oral
implant loss. They found a trend of more loss at
wide-diameter implants that were mostly in-
stalled in site with poor bone quality and quan-
tity. The treatment of implants with advanced
bone loss and deep V shaped defects was in our
study difcult because pocket elimination and
bone re-contouring could not be completed and
the access for mechanical debridement/deconta-
mination was limited. For this type of defect, a
regenerative/defect ll procedure and the use of
antibacterial aids could be benecial. However,
studies on the efcacy of such treatments in the
cases of peri-implantitis associated with an ad-
vanced bone loss are still at best limited (Claffey
et al. 2008; Renvert et al. 2008a, 2008b).
The number of implants with peri-implant
disease was slightly higher at the sixth-month
compared with the third-month examination.
One possible explanation could be that the sys-
temic antibiotic given before the surgical proce-
dure delayed the proliferation of the sub-mucosal
bacteria left following treatment, but this anti-
microbial effect during the rst 3-month period
was not longer sustained at the sixth-month
examination. The sites, which were healthy at
6 months, tended to remain stable over the 2-year
period. Fromthese ndings, it could be suggested
that an evaluation at 3 months may be too early
to predictably gauge the success of treatment, but
the corresponding gures at 6 months should be
more accurate.
Conclusion
The results of this study indicated that a surgical
procedure based on pocket elimination and bone
re-contouring before and following surgery was
an effective therapy for treatment of peri-implan-
titis for the majority of subjects and implants.
However, complete disease resolution at site
level seems to depend on the initial bone loss
around the implants. Implants that became
healthy following treatment remained healthy
during the 2-year period, while a tendency for
disease progression was observed for the implants
that still showed signs of peri-implant disease
following treatment.
Acknowledgements: The authors are
grateful to Dr. Patrick Holmes, Seven Fields
Dental Health Centre, Swindon, England, for
his help with the revision of the English text of
the manuscript. Conict of interest and
source of funding statement: The authors
declare no conict of interests. No external
funding, apart from the support of the authors
institution.
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Serino & Turri Outcome of surgical treatment of peri-implantitis
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